UCSD LGBT Staff and Faculty Association
9500 Gilman Drive, La Jolla, CA 92093
2014-15 Membership Form
Yes, I would like to be a member of the UCSD LGBT Staff and Faculty Association!
Name:
Mail Code:
Work Phone:
E-mail:
Affiliation (circle one):
Staff
Faculty
Other:
Department:
Location (circle one):
Torrey Pines
Main Campus
Scripps
Medical Center – La Jolla
Medical Center – Hillcrest
Other:
Identify as: Lesbian Gay Bisexual Transgender Questioning Ally
Other:
Referred By:
Annual membership runs July 1st through June 30th. No dues are required to become a member.
Donations are welcome and help to support expanded activities and benefits for UCSD LGBT SFA
members.
Your participation is vital to a vibrant UCSD LGBT SFA. Please indicate any talents or skills you
would be interested in contributing to the group:
I am interested in getting involved in the following: (check as many boxes as apply)
Acting as Communication Chair (posting on Facebook, emailing the mailing list)
Organizing speaker panels
Organizing social events
Tabling
Fundraising
Graphic Design
Suggestions / Comments (we’d love to hear your ideas for events and activities):
Please mail to completed membership form and check to Anna Levitt, Mail Code 0908, or return by email to
alevitt@ucsd.edu.
Thank you for joining our community.